New York improperly billed Medicaid for dentists’ services

By Jeffrey H. Brochin, J.D.

The HHS Office of Inspector General (OIG) conducted a series of reviews of claims submitted for Medicaid reimbursement by the New York State Department of Health (NYSDH) for dental services billed by two dentists and determined that in both practices, non-compliance issues resulted in unallowable reimbursements totaling $166,000. In both cases, one involving a Westchester County dentist and the other one a Queens dentist, the OIG audit found that dental colleagues who were not enrolled in the Medicaid program provided services for which claims were filed, and that adequate documentation to support the services billed was lacking. The reports recommended refunds of the improper payments as well as re-education of the dentists involved as to Medicaid billing requirements (OIG Report, No. A-02-13-01033, January 26, 2017; OIG Report, No. A-02-13-01034, January 26, 2017).

Dental services. Medicaid covers essential dental services for Medicaid-eligible beneficiaries. In an April 2012 hearing on government efforts to address Medicaid fraud, Congress noted its concerns on waste, fraud, and abuse of certain Medicaid program services, including dental services. Based on Congress’ concerns, the OIG conducted a series of reviews of claims submitted for Medicaid reimbursement by the NYSDH for dental services billed by dentists identified as being potentially at risk for noncompliance with certain federal and state requirements. In the course of the reviews, the OIG identified two dentists who were at risk for billing a potentially excessive number of services during the audit periods.

Westchester County dentist. The Westchester County dentist provided dental services to underserved urban and rural populations at two fixed locations and multiple mobile dental units. The dentist employed or contracted with approximately 25 dentists during the OIG’s audit period of January 1, 2010, through June 30, 2012. During the audit period, the dentist received Medicaid reimbursement totaling $1,927,875 for diagnostic, preventive, endodontic, and restorative dental services provided to 9,804 beneficiaries. Of those beneficiaries, the OIG selected a random sample of 100 beneficiaries and reviewed corresponding claims documentation.

The OIG found that out of the 100-beneficiary sampling, claims associated with 22 of those beneficiaries did not comply with federal and state requirements. For 14 of the 22 beneficiaries, the dentist who performed the services was not enrolled in Medicaid. For services provided to eight other beneficiaries, the dentist did not provide documentation to support the services billed. The OIG estimated that the NYSDH claimed at least $84,437 in federal reimbursement for unallowable dental services billed by the Westchester County dentist.

Queens dentist. The Queens dentist operated a group practice that provided pediatric dental services to underserved urban populations at four locations throughout the borough of Queens. The practice employed several dentists during the January 1, 2010, through June 30, 2012 audit period, during which time the dentist received federal Medicaid reimbursement totaling $918,765 for diagnostic, endodontic, general services, oral surgery, periodontics, preventive, and restorative dental services provided to 4,192 beneficiaries. The OIG again used a random sampling of 100 beneficiaries as the basis for its claims review, and found that 33 of those beneficiaries had dental services performed on them by dentists who were not enrolled in Medicaid. As a result of the non-compliance, the OIG estimated that the NYSDH claimed at least $82,967 in federal Medicaid reimbursement for unallowable dental services.

OIG recommendation. In both cases, the OIG recommended that the NYSDH refund the amount of the claims that were based on unallowable dental services, and that the state agency take measures to ensure that future reimbursement claims are only submitted for services rendered by dentists who are enrolled in the Medicaid program. This latter recommendation would require re-educating the dentists as to proper Medicaid billing requirements.